The Long, Mad Century

Historians like to mess around with dates. Most people would argue that the nineteenth century began on January 1st, 1800 and ended on December 31st, 1899, but those specific dates, however important in a timekeeping sense, do not always match when people feel that the century changed. When it felt like a brand, new century. Most people reading this will remember January 1st, 2000 (or maybe January 2nd, or 3rd, depending if you were partying like it was 1999). Did it feel like a new century? Or did the fall of the Berlin Wall on November 9th, 1989, or perhaps September 11, 2001, feel more like the end of an era and the start of a new one?

In many places the centenary of the beginning of the First World War in August 1914 is being commemorated. For many historians, the start of this conflict heralded the 'real' end of the nineteenth century, when the imperial European powers who had dominated the globe for centuries began to diminish and the powers that would dominate most of the rest of the twentieth century - the United States and the Soviet Union - began their ascendancy. So, when did this 'longer' nineteenth century begin? In Europe, many cite the storming of the Bastille on July 14,1789 and the start of the French Revolution as the true bookend for the 'long' nineteenth century, which would stretch out to 125 years, rather than the customary 100.

So, what does this have to do with mental health? Well, those dates, 1789 and 1914, also accord somewhat with an important development in the history of mental illness, specifically, the rise of the lunatic asylum. It may seem strange that the release of prisoners from the Bastille may hark the beginning of the asylum era, but toward the end of the eighteenth century - and because of many of the ideals that marked the French Revolution - many societies were seeking a different solution to the problem of madness, just as they were to other health issues. The construction of asylums and the passing of legislation to encourage authorities to do so can be seen in some ways as an extension of Enlightenment optimism, that by taking a rational approach, society could rid itself of many health problems, including madness.

Some of the legislation that was passed, including British legislation such as the Madhouse Act of 1774 and the County Asylums Act of 1808, was designed to improve the private facilities already in place and to urge local authorities to take responsibility for the mad. There were, of course, venerable asylums, such as Bedlam Hospital in London, and a host of small, private 'madhouses' - in addition to the care provided in the home, but there was the sense that many of these places warehoused patients at best, with abuse rife in many cases. In Britain, however, it took additional legislation - the Lunacy Act and County Asylum Act (1845) - before the building of asylums really took off.

Many of the asylums built following the 1845 legislation, along with those built in the United States and elsewhere, were located in bucolic, rural settings, far away from the helter-skelter of urban, industrial life, itself increasingly thought to be pathological. As with contemporary legislation related to public health, such as that concerning sanitation, such acts were meant to be examples of compassionate social reform, providing state-of-the-art humane care, often in spacious, idyll settings. The moral treatment on offer was often a mixture of talk therapy, occupational therapy, a familial atmosphere, and simply time to recover from the stresses and strains of modern life.

Of course the reality was often different. Gartnavel Asylum in Glasgow, which is celebrating its 200th anniversary this year, provides an example of how nineteenth-century asylums were complex institutions. Gartnavel was originally built near the city centre in 1814, but was moved to the leafy, more salubrious west end in 1843 to escape noise and pollution. Occupational therapy was a pillar of treatment and a range of entertainments were available for patients, along with a library and visits from family and friends; rooms were 'fully and comfortably furnished.' But at Gartnavel, along with similar asylums, a patient's treatment and experience also depended markedly on class. Working class patients were segregated from middle class patients, leading to considerable differences in care and treatment. Although restraint was abolished at Gartnavel in the 1840s, it would return in later decades. As in many instances in mental health, a profound gulf could exist between theory and practice.

The United States also experienced a book in asylum building beginning in the mid-nineteenth century. A 'cult of curability' emerged in the 1820s and 30s, with asylum superintendents claiming that nearly 90% of their patients left fully cured after a stay at their asylum. Later, mental health advocates, most notably Dorothea Dix (1802-1887) advocated the building of state hospitals to house the indigent insane. Influenced by the British lunacy reform movement, Dix inspected asylums and lobbied for legislation to improve services. Though she managed to convince both houses of Congress to pass the Bill for the Benefit of the Indigent Insane in 1854, it was vetoed by President Franklin Pierce. Nevertheless, asylum building continued apace in the United States.

If 1789 can be seen as the starting point for the asylum movement, why might 1914 be seen as the year in which this trend in mental health care ended? The answer can be found in the trenches of the First World War and the emergence of a new, disturbing disorder: shell shock. Recognition of shell shock amounted to a sea change in terms of how mental illness, particularly in a military context,was understood. At the start of the war, a soldier exhibiting symptoms of shell shock might have been summarily executed for malingering or desertion; indeed many were. By war's end, thousands and thousands of soldiers were taken away from the front to receive treatment for the disease. Although this treatment occurred in asylums, most soldiers would eventually return to their communities, as living testimonials to the horrors - and pathology - of war, much like the thousands of soldiers who bore the physical hallmarks of trench warfare, such as a missing limb, eye patch or prosthetic nose. Shell shock, partly because of its scale, partly because of those whom affected, and partly because of its cause made it difficult to blame the sufferer, brought mental illness to the masses like never before. Rather than shut away those afflicted in rural asylums, shell shock became central to how the Lost Generation was understood, and was depicted in the writing of Hemmingway, Fitzgerald, and others.

In this way, shell shock became one of the first mental afflictions whose sufferers were treated in a sympathetic, understanding manner, in some ways starting the process by which mental illness was destigmatized and, by extension, seen as a condition that should be treated in the community, rather than in an asylum. Similarly, the Second World War and the Vietnam War, as well as subsequent conflicts, have had a major impact upon how mental illness has been perceived. This is a subject to which I will return in more detail; suffice it to say now that, as we commemorate the beginning of the First World War (and the true start of the twentieth century), we should also remember some of its subtler consequences.